Management of Head Injury

University Pelita Harapan Faculty of Medicine keep young with charming students

Head Injury

10% of A/E workload Significant cost Expeditious management reduces secondary brain injury Associated injuries and secondary effects High proportion of patients have a subsequent disability

Pathophysiology of TBI

Cerebral Herniation
Subfalcine (Cingulate) Central Uncal (Transtentorial) Tonsillar (Foramen Magnum) Sphenoid (Alar) Transcalvarial Extra Cranial

Pre-Hospital Care
Airway management Transportation Properly trained professionals Prevention of secondary injury

Prehospital Management

Double-convex sign
Epidural Haematoma

Epidural Haematoma

Operation Procedure

Subdural Haemorrhages

Subdural Hemorrhage

Early Surgery of SDH

Early

Pre Op

Surgery

Post-op

Delayed Surgery of SDH

2 0 ho

urs
Acci dent

Base of skull fracture

Periorbital bruising Subconjunctival haemorrhage CSF rhino/otorrhoea Epistaxis Haemotympanum Battles sign

HISTORY
Mechanism of Injury (MOI)

Fall RTA Assault Blunt or penetrating trauma Associated injuries ALCOHOL

Symptoms

LOC Amnesia Nausea and/or vomiting Epistaxis Visual disturbance Headache Dizziness/drowsiness

GLASGOW COMA SCALE

Eye opening 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1 eyes open spontaneously open to speech open to pain no opening obeys commands localizes to pain flexion abnormal flexion extension no movement orientated confused inappropriate words incomprehensible sounds no speech

Motor response

Verbal response

Indications for referral to hospital

GCS < 15 at any time since the injury Amnesia Neurological symptoms Clinical evidence of a skull fracture Significant extracranial injuries MOI not trivial Continuing uncertainty about diagnosis Medical co-morbidity Adverse social factors

Skull x-ray indications

GCS < 15 or GCS 15, but: MOI not trivial LOC Amnesia or has vomited Full thickness scalp laceration/boggy haematoma Inadequate history

Skull X-ray
Advantages
Quick No need for radiologist Low dose of radiation (0.14mSv) Inexpensive

Disadvantages
Increased workload Inconclusive

CT Indications - SIGN

GCS 12/15 or less Deteriorating GCS or progressive focal neurological signs Confusion or drowsiness (GCS 13-14) followed by failure to improve within at most 4 hours of clinical observation Radiological/clinical evidence of fracture GCS 15, no fracture but:

Severe/persistent headache, N+V, irritability or altered behaviour, seizure

CT Scan
Advantages
High sensitivity/specificity Detection of intracranial haematoma Definitive (except ultra early)

Disadvantages
High dose of radiation (2.0mSv) Radiologist required

EPIDURAL HEMATOMA

Associated with skull fracture. Classic : Middle meningeal artery tear. Lenticular/biconvex due to dural adherence to skull. Lucid interval.

EPIDURAL HEMATOMA

Can be rapidly fatal. Early evacuation good prognosis. Venous epidurals, Possible nonsurgical management.

SUBDURAL HEMATOMA

Venous tear/brain laceration. Covers entire cerebral surface. Morbidity/mortality due to underlying brain injury. Rapid surgical evacuation recommended especially if > 5mm shift of midline.

CONTUSION/HEMATOMA

Coup/contrecoup injuries. Most common : frontal/temporal lobes. Salt & pepper appearance on CT. CT changes usually progressive. Most conscious patients : no operation.

Admission or Discharge?

GCS < 15 GCS 15, but

Continuing amnesia Continuing nausea/vomiting Severe headache Any seizure Focal neurological signs Skull fracture Abnormal CT

Significant medical problems Social problems/no supervision at home

Discharge from A/E

None of the above exclusion criteria Patient must be given head injury advice Responsible adult to supervise the patient Easy access to a telephone Reasonable access to a hospital Easy access to transport

Transfer to Neurosurgery

Abnormal CT scan CT is indicated but cannot be done within an appropriate period Clinical features which warrant neurosurgical assessment, monitoring or management:

Persisting coma (GCS 8/15) Persisting confusion Deteriorating GCS Progressive focal neurology Seizure without full recovery Depressed skull fracture Penetrating injury CSF leak/BOS fracture

Medical Management
Intra venous fluids Euvolemia. Isotonic. Hyperventilation, if necessary Goal : PaCO2 at 25 - 35 mmHg.

Medical Management

Mannitol Use with signs of increased ICP Dose : 0,5 - 1,0 g/kg IV bolus. Other Anticonvulsants. Sedation. Paralytics

Surgical Management Scalp injuries

Possible site of major blood loss. Direct pressure to control bleeding. Occasional temporary closure.

Surgical Management Intracranial Mass Lesion

May be life-threatening if expanding rapidly. Immediate neurosurgical consult. Hyperventilation/Mannitol. ? Emergency burr holes ?

QUESTIONS?